| NPI | 1093444606 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: GA 98041) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| 208D00000X General Practice (Licence: GA 98041) | |
| Enumeration Date | 2022-06-08 |
| Last Update Date | 2025-06-10 |